My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • 1. Appeal the decision;
  • 2. Request an independent medical review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. Your insurer may offer two levels of internal appeals. The first level is required and the second level is optional.

To request a first level appeal, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited internal appeal, if applicable. If you are requesting urgent care involving an admission, availability of care, continued stay, or health care service in which you have received emergency services but have not been discharged from the facility, you can request an expedited internal review.[2] Your insurer must provide you with information regarding how to submit the request and any required documentation you will need to submit with the request.[3] You can request an expedited appeal over the phone, in writing, or by email to your health insurer.[4]
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

If your insurer denies your claim after the first level internal appeal, you can request a second level of internal appeals.[5] This second level internal appeal is entirely optional.[6]

Your health insurer is required to provide you with notice and instruction on how to file a second level appeal with their denial letter following the first level internal appeal.[7] During a second level internal appeal, you have the right to:

  • Appear in person before a review panel convened by your health insurer;
  • Receive copies of all documents, records, and other information relevant to your request for services or treatment;
  • Present your case to the review panel;
  • Submit additional documentation and information to the review panel for their consideration; and
  • Ask questions of the review panel.[8]

The first level appeal should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.[9] The second level internal appeal should take a maximum of five business days following the review meeting.[10]

If you request an expedited internal appeal, your health insurer should send you a decision within 72 hours of receiving the request.[11]

During an external review, an independent third party reviews your insurer’s decision.[12] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Tennessee law, you are entitled to request an external review in the following circumstances:

  • Your insurer denies your internal appeal;[13]
  • Your insurer did not send you a decision on your internal appeal within the required deadlines.[14]

You can also request an expedited external review if your situation is urgent and waiting would jeopardize your life or ability to function.[15]  If your situation is urgent, you can request an expedited external review simultaneously with your request for a first level appeal.[16]

You should submit your request for an external review to your health insurer within six months from when your insurer sent you its final decision.[17] Your health insurer must provide you with instructions on how to submit your request.[18] You should submit any new information that you did not previously provide to your health insurer with your request.[19]

Once you submit your request for an external review, your health insurer will then send your request to an external review organization for review.[20] Your health insurer will also send you a notice that an external review organization has been assigned to your case and instructions on how and where to send additional information.[21]

The external review process should take no more than 40 days after the external review organization receives your request.[22] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[23]

If you are a Tennessee resident and your insurer still denies your claim after the external review process, you can file a complaint with the Tennessee Department of Commerce and Insurance, Division of Insurance (“Division”).

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The names of other parties involved;
  • The name of the insurance company, insurance agency, and agent/adjuster/appraiser;
  • The state in which you purchased the plan;
  • The policy number, certificate number, claim number, and date of loss;
  • The type of insurance and reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[25]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[26]

How to submit. The complaint may be submitted online here, faxed to (615) 532-7389, or mailed to the following address:

Consumer Insurance Services
500 James Robertson Parkway, 6th Floor
Nashville, TN 37243-0574[27]

The Division will forward a copy of your complaint to your health insurer, who has two weeks to respond. The Division will review the insurer’s response. If the Division determines that your insurer violated your insurance policy, the Division will require your insurer to comply. The complaint process time varies, but typically takes one month to complete.

You can contact the Tennessee Department of Commerce and Insurance at (615) 741-2241. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.